Complete this form if you wish to volunteer your services to support our community impacted by the fires.

By signing up, you are committing to offer SIX FREE sessions to those in need and Maple will provide the referral to your practice.

If the client wants ongoing therapy upon conclusion of the six free, you can refer them back to Maple or keep them as a client in your own practice.

If you are licensed in CA and located elsewhere, you may provide telehealth services to CA clients in need.

Update 1/17/25: we have received over 60 applications in less than 3 days offering over 360 free sessions to those in need. Thank you and please keep the applications coming!

Update 1/22/25: we have received 100+ applications and are matching clients with volunteer clinicians every weekday during business hours.

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Required*

First Name*

Last Name*

Email Address*

Phone*

Address*

Please confirm that you are willing to provide at least 6 free sessions:*

Please list all days and times that you are available to help and specify whether it is in-person, online, or both:*

If in-person services are available, please list all possible locations (if different than above or any additional sites):

Please indicate the preferred way for Maple Counseling to connect you with potential clients:* Please have the client contact me directly.Please have the Welcome Center staff call me to provide a brief overview of the case.Please have the Welcome Center staff email me to provide a brief overview of the case.

Are you able to provide therapy in any other languages?

Are there any professional bullet points (such as training and specialization) that you would like us to share with the client and/or anything unique that you would like us to communicate about your practice?

Do you take insurance? If so, which plans:

Are you trained in Psychological First Aid (PFA) and/or Skills for Psychological Recovery (SPR)?

Not necessary to help / Check all that apply* Psychological First Aid (PFA)Skills for Psychological Recovery (SPR)No, I am not.

Are you willing to be part of our Maple Counseling's Mobile Unit that goes to shelters providing help?*

Please add most updated resume if available, and if not, please skip:

Do you have a professional web presence that you would like us to share with the client (such as website, social media, Psychology Today)?

Please indicate whether any of the following is true:* Maple Alumn (Trainee)Maple Alumn (Staff)Maple Volunteer Clinical Supervisor (Past or Present)Maple Board Member (Past or Present)Other Maple Clinical Volunteer (Past or Present)This is my first time volunteering for Maple (Thank You!)

Are you interested in future leadership? Please check all that apply: Volunteer Clinical SupervisorBoard MemberAdvisory BoardAlumni SubcommitteeSchool Subcommittee (LAUSD, BHUSD, Private School)Welcome Center Subcommittee (Amplifying our Services)

Human Check*

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Fire Relief Clinical Volunteer (Licensed)

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